Sunday, April 14, 2013

Bipartisan Agreement on Treating Mental Illness - Believe It when You See It

The New York Times has an incredibly naive article on how legislators may be split on gun control but both parties support better care for people with mental illnesses. The article alludes to a bipartisan plan that would "prevent killers .....from slipping through the cracks." The next paragraph says that the plan: "would lead to some of the most significant advancements in years in treating mental illness and address a problem that people on both sides of the issue agree is a root cause of gun rampages."That would be groundbreaking news if it were true, but let's be realistic. The history of funding treatment for addictions and mental illnesses in this country has been a downhill spiral for at least 30 years and there are no real signs that will changed. Congress has essentially been at the root of the problem. Congress after all is responsible for the disproportionately poor level of funding for the treatment of mental illness. Congress basically invented the managed care and pharmacy benefit manager industry that has increased the rationing of psychiatric services that has led to the current deterioration. Rather than focus of providing quality in the services that federal, state, and local governments typically provide (like community mental health centers, case management, civil commitment, protective services, and crisis intervention) they have adopted the managed care model of rationing services. The only relative bright spot in mental health legislation was a parity law spearheaded by Senators Wellstone and Domenici. The actual boilerplate is one thing and there was always a question about managed care would react to the parity law and if they could continue their successful rationing techniques. Events in the past week suggest that they are as evidenced by the New York State Psychiatric Associationand the Connecticut Psychiatric Societyjoining in a class action lawsuit against United Health Care and Anthem Health Plans for violations of the Mental Health Parity and Addiction Equity Act (MHPAEA). The interesting aspect of the alleged "violations" is that they are standard rationing tactics that have been used by this industry for decades.There are surprisingly few details of "improved mental health care" provided in this article. There are many legislative tricks to make it seem like something has happened when it really has not. The mental health issue seems like a safe haven for legislators who don't really want to address the gun issue. I have posted some of the rhetoric on the issue here and some of it is fairly grim. The President's initiative in the article involves over $100 million for screening. There is no good evidence that screening adds much more than getting people on medications as fast as possible - probably too many people.A related issue with Congressional lawmaking is that they rarely seem to consult anyone with expertise. Many consider themselves to be experts in something even though they have never trained or worked in the field. The people with the most significant access are business lobbyists and in many cases they are writing the laws or at least very satisfied with what is happening. The focus is generally on improving the wealth of the folks with the lobbyists. That is unfortunate because there are numerous ways to improve the provision of psychiatric services for severe mental illness without giving away more money to managed care companies. The idea that "the most significant advancements in years in treating mental illness" will come out of Congress and business lobbyists sets my teeth on edge.

George Dawson, MD, DFAPA

Jeremy W. Peters. In Gun Debate No Rift On Care for the Mentally Ill. New York Times April 12, 2013.